[PDF] Form 9465 (Rev. September 2020)

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Form 9465

(Rev. September 2020)

Installment Agreement Request

Department of the Treasury

Internal Revenue Service

Go to www.irs.gov/Form9465 for instructions and the latest information. If you are filing this form with your tax return, attach it to the front of the return.

See separate instructions.

OMB No. 1545-0074

Tip: If you owe $50,000 or less, you may be able to avoid filing Form 9465 and establish an installment agreement online, even if you

haven't yet received a tax bill. Go to www.irs.gov/OPA to apply for an Online Payment Agreement. If you establish your installment

agreement using the Online Payment Agreement application, the user fee t hat you pay will be lower than it would be with Form 9465.

Part IInstallment Agreement Request

This request is for Form(s) (for example, Form 1040 or Form 941) Enter tax year(s) or period(s) involved (for example, 2018 and 2019 , or January 1, 2019, to June 30, 2019)

1 a Your first name and initial Last name Your social security number

If a joint return, spouse's first name and initial Last name Spouse's social security number Current address (number and street). If you have a P.O. box and no hom e delivery, enter your box number. Apt. number City, town or post office, state, and ZIP code. If a foreign address, al so complete the spaces below (see instructions).

Foreign country name

Foreign province/state/county Foreign postal code

1 b If this address is new since you filed your last tax return, check here

2 Name of your business (must no longer be operating)Employer identification number (EIN)

3

Your home phone number Best time for us to call

4 Your work phone number Ext. Best time for us to call

5 Enter the total amount you owe as shown on your tax return(s) (or not

ice(s)) ........5

6 If you have any additional balances due that aren't reported on line 5, enter the amount here (even if

the amounts are included in an existing installment agreement)............6

7 Add lines 5 and 6 and enter the result ....................7

8 Enter the amount of any payment you're making with this request. See

instructions .....8

9 Amount owed. Subtract line 8 from line 7 and enter the result ............910Divide the amount on line 9 by 72.0 and enter the result ..............10

11 a Enter the amount you can pay each month. Make your payment as large as possible to limit interest and penalty charges, as these charges will continue to accrue until you pay in full. If you have an existing installment agreement, this amount should represent your total proposed monthly payment amount for all your liabilities. If no payment amount is listed on line 11a, a payment will be determined for you by dividing the balance due on line 9 by 72 months 11a$

b If the amount on line 11a is less than the amount on line 10 and you're able to increase your payment

to an amount that is equal to or greater than the amount on line 10, ent er your revised monthly payment 11b$ • If you can't increase your payment on line 11b to more than or e qual to the amount shown on line 10, check the box. Also, complete and attach Form 433-F, Collection Information Statement................... • If the amount on line 11a (or 11b, if applicable) is more than or equal to the amount on line 10 and the amount you owe is over $25,000 but not more than $50,000, then you don't have to comple te Form 433-F. However, if you don't complete Form

433-F, then you must complete either line 13 or 14.

• If the amount on line 9 is greater than $50,000, complete and attach Form 433-F.

12Enter the date you want to make your payment each month. Don't enter a date later than the 28th

12

13 If you want to make your

payments by direct debit from your checking account, see the instructions and fill in lines 13a and

13b. This is the most convenient way to make your payments and it will e

nsure that they are made on time. a Routing number b Account number

I authorize the U.S. Treasury and its designated Financial Agent to initiate a monthly ACH debit (electronic withdrawal) entry to the financial institution account

indicated for payments of my federal taxes owed, and the financial institution to debit the entry to this account. This authorization is to remain in full force and

effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke payment, I must contact the U.S. Treasury Financial Agent at

1-800-829-1040

no later than 14 business days prior to the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payments of taxes to receive confidential information necessa ry to answer inquiries and resolve issues related to the payments. c

Low-income taxpayers only. If you're unable to make electronic payments through a debit instrument by providing your

banking information on lines 13a and 13b, check this box and your user fee will be reimbursed upon completion of your

installment agreement. See instructions.......... ..................14If you want to make payments by payroll deduction, check this box and at tach a completed Form 2159.......

By signing and submitting this form, I authorize the IRS to contact third parties and to disclose my tax information to third parties in order to process this

request and administer the agreement over its duration. I also agree to the terms of this agreement, as provided in the instructions, if it's approved by the IRS. Your signature Date Spouse's signature. If a joint return, both must sign. Date

For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 14842Y Form 9465 (Rev. 9-2020)

Form 9465 (Rev. 9-2020) Page 2

Part IIAdditional Information

Complete this Part only if all three conditions below apply:

1.You defaulted on an installment agreement in the past 12 months;

2.You owe more than $25,000 but not more than $50,000; and

3.The amount on line 11a (or 11b, if applicable) is less than line 10.

Note: If you owe more than $50,000, also complete and attach Form 433-F.

15In which county is your primary residence?

16 a Marital status:

Single. Skip question 16b and go to question 17.

Married. Go to question 16b.

b Do you share household expenses with your spouse? Yes. No.

17How many dependents will you be able to claim on this year's tax retu

rn?......... 17

18How many people in your household are 65 or older? ...............18

19How often are you paid?

Once a week.

Once every 2 weeks.

Once a month.

Twice a month.

20What is your net income per pay period (take home pay)? ..............

20$ Note: Complete lines 21 and 22 only if you have a spouse and meet certain cond itions (see instructions). If you don't have a spouse, go to line 23.

21How often is your spouse paid?

Once a week.

Once every 2 weeks.

Once a month.

Twice a month.

22What is your spouse's net income per pay period (take home pay)?...........

22$

23How many vehicles do you own? ......................

23

24How many car payments do you have each month? ...................24

25
a Do you have health insurance? Yes. Go to question 25b.No. Skip question 25b and go to question 26a. b Are your health insurance premiums deducted from your paycheck? Yes. Skip question 25c and go to question 26a.No. Go to question 25c. cHow much are your monthly health insurance premiums? .............. 25c$
26
a Do you make court-ordered payments?

Yes. Go to question 26b.No. Go to question 27.

b Are your court-ordered payments deducted from your paycheck?

Yes. Go to question 27.No. Go to question 26c.

cHow much are your court-ordered payments each month? ............. 26c$

27 Not including any court-ordered payments for child and dependent support, how much do you pay

for child or dependent care each month? ................... 27$

Form 9465 (Rev. 9-2020)

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